Case of the Month
Case of the Month
Case of the Month - October 2021


    Checking the general condition before starting work is an essential examination step that can change the diagnostic and therapeutic approach for each patient.

    Habitus: Depression, inability to keep the head still, tremors and weakness in the front extremities were observed.
    Nutritional status: Good
    P: 120 beats/min, Pulse quality: Normal
    R: 38 breaths/min, Respiration type: Costoabdominal, Auscultation: Normal
    Capillary refill time: 1s, Peripheral pulse: Strong
    Mucous membranes: Pale
    Lymph nodes: Normal
    Abdominal Palpation: Normal
    Rectal palpation: Not done

    Neurological Examination:
    In this step, basic functions of the nervous system are checked.
    There were signs of ataxia, incoordination, and pain on palpation of the cranial neck region.
    Cranial nerves: Pupillary light reflex: Delayed, Threat response: Normal, Corneal-Palpebral Reflex: Normal, Nystagmus: None, Labial reflex: Normal.
    Deep pain sensation: Normal, Proprioception: Delayed, Muscle tone: Increased, Wheel barrowing: Negative, Bounce: Negative.

    Odin's blood was taken and a haemogram test was performed.

    Bloodwork did not reveal any evidence that could explain the clinical signs.

    In order to determine the localization of the lesion according to the neurological examination findings, radiographic examination of the head and neck region was performed under general anaesthesia for proper positioning of the cervical vertebrae.

    Did you see the lesion?

    Figure 1: Lateral radiographs taken in neutral position (left) and with mild flexion (right).

    Figure 2: To compare Odin's condition, notice the normal alignment of the vertebrae on the lateral radiograph taken from the neck of a healthy 5-year-old Yorkshire terrier (Left). Odin’s lesion is indicated by the red arrow (right).

    Interpretation of radiographic imaging showed a misalignment between the first and second cervical vertebrae and a significant increase in the distance between both vertebrae. The atlas was displaced dorsally creating also a gap between atlas and occiput.

    👍 Congratulations, correct diagnosis.

    The atlantoaxial joint consists of the first 2 cervical (C) vertebrae, the atlas or C1, and the axis or C2. There are 5 ligaments that provide the stability of the atlantoaxial joint; these are transversal, apical, dorsal atlantoaxial and 2 alar ligaments. Atlantoaxial subluxation (AAS) occurs with abnormal movement of the joint. AAS is most commonly caused by congenital anomalies and is often seen in young, small or miniature breed dogs. Congenital anomalies seen in AAS are aplasia or hypoplasia of the dens, absence or weakness of the supporting ligaments, incomplete ossification of the atlas, block vertebrae, and dorsal angulation of the dens. Abnormal movement of the atlantoaxial joint causes dorsal subluxation of the axis and compression of the spinal cord. Clinical manifestations vary according to the degree of spinal cord compression and range from cervical pain to tetraplegia, respiratory paralysis and death. Traumatic atlantoaxial subluxation (TAAS) occurs when cervical spine trauma leads to instability of the atlantoaxial joint, either from C1-C2 fractures, damage to supporting ligaments, or both (de Lahunta, 2009; Hansen, 2019). Best diagnostic method is computed tomography, which would enable three dimensional evaluation of the case. Treatment methods can be conservative (neck supported bandage + movement restriction) or operative (dorsal/ventral vertebral cerclage, stability with pin, screw, plate and suture materials). The prognosis is always guarded and varies according to the clinical symptoms of the patient and treatment (de Lahunta, 2009; Stalin, 2015).


    The possibility of surviving with neck support was evaluated. However, due to the severity and localization of the lesion, it was decided that this method would not be useful, considering that sufficient stability could not be achieved.
    Due to the severity of the lesion, the prognosis of the operative treatment was guarded and the operative method was not considered appropriate.

    👎 Sorry, misdiagnosed!

    Together with Odin's owner, it was decided to euthanize him before his symptoms further worsened.
     
    Further Reading
    de Lahunta, A and Glass, EN. de Lahunta’s Veterinary Neuroanatomy and Clinical Neurology. Elsevier Health Sciences, 2009.
    Hansen, Sonya C., et al. "Traumatic atlantoaxial subluxation in dogs: 8 cases (2009–2016)." Journal of Veterinary Emergency and Critical Care 29.3 (2019): 301-308.
    Stalin, C., et al. "A review of canine atlantoaxial joint subluxation." Veterinary and Comparative Orthopaedics and Traumatology 28.01 (2015): 1-8.

    Case of the Month - May 2021


      Checking the general condition before starting work is an essential examination step that can change the diagnostic and therapeutic approach for each patient.


      Habitus: Alert (related to its environment)
      Nutritional status: good
      P: 100 / min, pulse quality: normal
      R: 30 / min, respiratory costoabdominal, auscultation: vesicular sounds
      Capillary refill time: 2 sec, peripheral pulse: strong
      Mucosal color: rose-pink
      Lymph nodes: normal
      Abdominal palpation: normal
      Rectal palpation: normal

      Oral examination:
      On intraoral examination under sedation, it was observed that there was no problem related to teeth and gingiva.

      When the wounds were probed, it was determined that the wound had reached the maxillary bone.

      Ophthalmic examination:
      No physical examination findings affecting the eyeball and accessory organs were detected. Examination of the deep layers of the bulbus was not considered necessary.

      Complete blood count (CBC) was performed and leukocytosis (granulocytosis) was detected.

      Did you see the lesion?

      A radiolucent (black) halo indicating bone resorption was observed around the roots of both maxillary 4th premolars on oblique views of the right and left quadrants of the maxilla and mandible. In the light of these findings, it was suggested that the source of the fistula was the inflammation of the tooth roots.


      👍 Well done, correct diagnosis!


      Previous conservative treatment (without a full diagnosis) had been tried unsuccessfully by other vets.
      There is no conservative treatment of carnasial fistula.
      Under general anesthesia, both teeth were extracted operatively.
      After the operation, antibiotics and oral antiseptics were used, and an Elizabethan collar was attached to his head. A few days of soft food feeding was recommended.


      Intraoral connection of the fistula seen intra operatively.

      Post-operative radiographs show that both maxillary P4s were completely extracted without residue.

      👎 Sorry, misdiagnosed!

      On the 15th day after the operation, the sutures of Caramel were removed, the mouth is healed, the fistula wounds are about to close.

       

      Post-operative 30th day.

       

      The owner of Caramel stated that he is fine and happier and that he has regained his previous health. As Near East University Faculty of Veterinary Medicine Animal Hospital, we wish him "get well soon, Caramel".

      Authors: Assoc. Prof. Dr. Serkan SAYINER ve Assist. Prof. Dr. Çağrı GÜLTEKİN